69C.E.H. Scott-Conner (ed.), Chassin’s Operative Strategy in General Surgery, DOI 10.1007/978-1-4614-1393-6_10, © Springer Science+Business Media New York 2014

Purpose of Drains

Drains permit purulent material, blood, serum, lymph, bile, pancreatic juice, and intestinal contents to escape from the body. They form a walled-off passageway that leads from the source of infection or fl uid buildup to the outside. This pas-sageway, or tract, must persist for a period long enough to ensure complete evacuation of the collection, collapse of the cavity, and ultimately healing from the inside out.

In the presence of a discrete abscess, the need for and purpose of a drain is obvious and not controversial, as its therapeutic benefi ts are clear. In most other situations, the drain acts as a prophylactic instrument to prevent accumula-tion of undesirable products. Because it is a foreign body, the drain also has the paradoxical effect of potentiating infec-tion. When and how a drain should be used for prophylactic purposes has long been a source of controversy. Controlled trials have signifi cantly decreased the indications for “pro-phylactic” drainage; some are cited in the references at the end of the chapter.

Various Drains and Their Pros and Cons

Latex (Penrose) Drain

The Penrose drain is a soft latex drain of various dimensions. It has the shape of a fl attened cylinder and is made of a thin, radiopaque sheet of rubber. It has the advantage of being inexpensive. It is also successful in encouraging fi brosis, so it forms a well-established tract within 8–10 days.

It has many disadvantages as well. This is a completely passive drain, and fl uid exits around the drain by capillary action and gravity. Ideally, the drain is placed to create a dependent tract through which fl uid escape may be aided by gravity. If the surgeon does not take pains to bring the drain out in a straight line, without wrinkles, stagnant pools of serum accumulate around the wrinkled areas of the drain. After the drain is removed, the patient may have a 24-h increase in temperature of as much as 1 °C. More fundamen-tally, the passive latex drain does not empty a cavity; it sim-ply permits secretions to overfl ow from the abdomen to the outside. It is not particularly effective in evacuating oozing blood before a clot forms. There is no method by which the depth of the wound can be irrigated with this type of drain as there is when a tube or sump type is used.

Finally, the most important objection to the latex drain arises from the fact that it requires a 1- to 2-cm stab wound in the abdominal wall, which permits retrograde passage of pathogenic bacteria down into the drain tract. It also creates a sizable fascial opening that may be the site of subsequent hernia formation.

Penrose drains are also used for retraction, for example, when the esophagus is retracted during hiatal hernia repair.

Polyethylene or Rubber Tube Drain

These are also passive drains, but are tubular and more rigid than the Penrose drain. Both polyethylene and rubber tube drains establish tracts to the outside, as they are mildly irri-tating and stimulate adhesion formation. They effectively evacuate air and serum from the pleural cavity and bile from the common bile duct (so a chest tube, or a T-tube, would be examples of such drains). Drainage tract infection following the use of tube drains is rare for the reasons discussed below.

Among the disadvantages of rubber and polyethylene tubes is that they become clogged with clotted serum or

Rational Use of Drains

Carol E. H. Scott-Conner and Jameson L. Chassin†

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C. E. H. Scott-Conner , MD, PhD (*) Department of Surgery , Roy J. and Lucille A. Carver College of Medicine, University of Iowa , 200 Hawkins Drive, 4622 JCP , Iowa City , IA 52242 , USA e-mail: carol-scott-conner@uiowa.edu

J. L. Chassin , MD Department of Surgery , New York University School of Medicine , New York , NY , USA †Deceased

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blood unless they are large. Large tubes, however, are unsuit-able for placement deep in the abdominal cavity for a period of more than a few days, as there is considerable danger of erosion through an adjacent segment of intestine, resulting in an intestinal fi stula. These drains are, therefore, primarily used in selected applications such as pleural space drainage and biliary tract drainage as noted above.

Silicone Tube Drain

Silicone or Silastic tubes are less reactive than are other types of drain. They are less prone to become plugged as a result of clotting serum. Because of the soft texture of sili-cone, erosion into the intestine is uncommon.

A disadvantage of silicone drains is their lack of reactiv-ity; hence, there is minimal fi brous tract formation. This les-son was learned when Silastic T-tubes were (briefl y) used in the common bile duct, and their removal often resulted in bile peritonitis because a fi rm fi brous channel had not been established between the bile duct and the outside.

Sump Suction Drains

Generally constructed of silicone or polyethylene tubing, sump drains must be attached to a source of continuous suc-tion. They effectively evacuate blood and serum, especially if suction is instituted in the operating room so the blood is evacuated before it clots. The sump allows (generally fi ltered) room air to enter as suction is applied, much as a sump naso-gastric tube continuously aspirates air. This air intake channel can also be used for instillation of an antibiotic solution when indicated. If used regularly, fl uid instillation prevents obstruc-tion of the drain due to coagulation of serum or secretions. Drainage tract infections with sumps are uncommon even though unsterile, bacteria-laden air is drawn into the depths of the patient’s wound by the continuous suction. A major disad-vantage of sump drains is the requirement that the patient be attached permanently to a suction device, thereby impairing mobility. These drains are predominately used for very diffi -cult abscesses, such as those associated with peripancreatic sepsis, where other drains tend to stop working.

Closed Suction Drain

These are the commonest drains used in current practice. The closed suction drain consists of one or two multiperfo-rated silicone or polyethylene catheters attached to a sterile plastic container, the source of continuous suction. It is a closed system; and the catheters are brought out through puncture wounds. These drains have replaced other drains

for most applications. Patient mobility is unimpaired, as the plastic container is easily attached to the patient’s attire. The depths of the wound can be irrigated with an antibiotic solu-tion by disconnecting the catheter from the suction device and instilling the medication with a sterile syringe.

Closed suction drains are commonly used in a clean fi eld, such as at axillary node dissection sites to prevent seroma formation. They should be removed as soon as possible to prevent bacterial entry.

Some closed suction drains contain multiple perforations. In time, tissues are sucked into the fenestrations, and tissue ingrowth may even occur. This makes removal diffi cult (occasionally to the point of requiring relaparotomy), and most surgeons are reluctant to leave a fenestrated closed suc-tion drain in the abdomen for more than 10 days. Fluted (channel-type) suction drains are also available and avoid this potential complication.

Gauze Packing

When a gauze pack is inserted into an abscess cavity and is brought to the outside, the gauze, in effect, serves as a drain. Unless the packing is changed frequently, this system has the disadvantage of potentiating sepsis by providing a foreign body that protects bacteria from phagocytosis. Management of pan-creatic abscesses by marsupialization and packing is an example of this technique. Daily dressing changes keep the packing fresh.

Prevention of Drainage Tract Infection

Retrograde transit of bacteria from the patient’s skin down into the drainage tract is a source of postoperative sepsis and may even follow clean operations. When a polyethylene sump or a silicone closed suction catheter is brought through a puncture wound of the skin, it is easy to suture it in place and minimize or eliminate the to-and-fro motion that encourages bacteria to migrate down the drain tract. On the other hand, when a latex drain is brought out through a 1- to 2-cm stab wound in the abdominal wall, there is no possibility of eliminating the to-and-fro motion of the drain or retrograde passage of bacteria into the drainage tract. Consequently, when latex or gauze drains are required for an established abscess, the surgeon must accept the added risk of retrograde contamination with bacteria despite sterile technique when dressings are changed.

Management of Intraperitoneal Sepsis

When managing intraperitoneal sepsis, a distinction must be made between an isolated abscess (e.g., around the appen-dix) and multiple abscesses involving the intestines

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accompanied by generalized peritonitis. With the latter type of sepsis, the presence of fi brin and necrotic tissue prevents adequate phagocytosis and perpetuates sepsis.

When an abscess has developed rigid walls that do not collapse after evacuation of pus , large drains must be inserted to establish a reliable tract to the outside. Sometimes a rigid abscess cavity requires 2–5 weeks to fi ll with granulation tissue. It is not safe to remove the drains until injecting the abscess with an aqueous iodin-ated contrast medium has produced a radiograph demon-strating that the cavity is no longer signifi cantly larger in diameter than the drainage tract. If this is not done, the abscess may rapidly recur. For rigid- walled abscesses of this type, several large latex drains should be inserted together with one or two sump drains. Some surgeons place an additional straight 10F catheter for intermittent instillation of dilute antibiotic solution. At least one drain is left in place until the sinogram shows that the abscess cavity has essentially disappeared. Care should be taken that none of the rigid drains comes into contact with the intestine or stomach, as intestinal fi stulas can be a serious complication.

Percutaneous Drainage of Abdominal Abscesses with Computed Tomography or Ultrasound Guidance

Treatment of abdominal abscesses underwent a revolution-ary change during the 1990s owing to the demonstrated effi -cacy of percutaneous drainage by the interventional radiologist. In the case of most abdominal abscesses, the skilled radiologist can fi nd a safe route along which to insert a drainage catheter that evacuates the pus without a need to perform laparotomy for drainage. This technology is espe-cially welcome in the critically ill patient who may not toler-ate a major operation.

Other Indications and Methods of Drainage

Abscess

For abscesses of the extremities, trunk, or perirectal area, the important step is to unroof the abscess by making a cru-ciate incision so the tract does not close before all the pus has been evacuated. An unroofi ng procedure is adequate for superfi cial abscesses, and any type of temporary drain is suffi cient. When the danger exists that the superfi cial portion of the tract might close before deep healing takes place, insertion of gauze packing is indicated. The packing is then changed often enough to keep it from blocking the egress of pus.

Blood and Serum

The presence of blood, serum, or fi brin in a perfectly sterile area is not dangerous to the patient, although the operative fi eld is never completely sterile following any major opera-tion. For this reason, postoperative puddles of blood or serum in combination with even a small number of bacteria can result in abscess formation because the red blood cell impairs antibacterial defenses. With the low colorectal anastomosis, accumulated serum or blood in the presacral space, together with secondary infection and abscess formation, may result in anastomotic breakdown. For these reasons, strenuous efforts should be exerted to eliminate bleeding during any abdominal operation. If these efforts must be supplemented by some type of drainage, the ideal method is to insert one or two multiperforated Silastic drains, which are brought out through puncture wounds in the abdominal wall and attached to a closed suction system.

Closed suction drainage is extremely effective following radical mastectomy or regional lymph node dissections of the neck, axilla, or groin. Small-diameter tubing is accept-able. This technique has also been employed successfully following abdominoperineal proctectomy with primary clo-sure of the perineal fl oor and skin.

Bile

Because bile has an extremely low surface tension, it tends to leak through tiny defects in anastomoses or through needle holes. It is essentially harmless if a passageway to the out-side is established. A sump drain or closed suction system works well for this purpose. Silastic tubes are contraindi-cated whenever formation of a fi brous tract to the outside for the bile is desirable, especially with use of a T-tube in the common bile duct, as previously noted.

Pancreatic Secretions

It is not dangerous for pure pancreatic juice to drain into the abdominal cavity, as is evident in patients who have pancre-atic ascites or a fi stula. If the pancreatic secretion is activated by the presence of bile, duodenal contents, or pus, however, trypsinogen is converted to trypsin and the adjacent tissues are subjected to a raging infl ammatory reaction. Recently constructed adjacent anastomoses may be digested and destroyed. Eventually, hemorrhage from retroperitoneal blood vessels ensues.

Consequently, it is important to evacuate bile and pancre-atic secretions completely, especially after pancreaticoduo-denectomy. This is accomplished by inserting a long plastic catheter into the pancreatic duct in the tail of the pancreas. The

10 Rational Use of Drains

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catheter is brought through the segment of jejunum to which the duct is anastomosed. Then it is brought through a jeju-nostomy opening to an outside drainage bag. Unless the tube is accidentally displaced, it conveys all pancreatic secretions from the abdominal cavity. In addition, a suction catheter is inserted in the vicinity of the anastomosis, between the tail of the pancreas and the jejunum. Many surgeons routinely drain pancreatic staple lines or suture lines (e.g., after distal pan-createctomy or pancreaticojejunostomy) with closed suction drains.

Anastomosis

It makes little sense to place a drain down to a gastrointesti-nal anastomosis simply because the surgeon has some doubt about its integrity. If anastomotic breakdown occurs, the presence of a drain may not prevent generalized peritonitis. If the surgeon believes there is signifi cant risk of anastomotic failure, the anastomosis should be taken apart and done over, or else both ends should be exteriorized and reconnected at a second-stage operation. The surgeon must not fall into the trap of fuzzy thinking, which would permit acceptance of an anastomosis that might be less than adequate, rather than reconstructing the anastomosis or eliminating it from this stage of the operation.

When treating Crohn’s disease accompanied by extensive cellulitis, some surgeons believe the infl amed areas should be drained. In reality, cellulitis or contamination, such as might follow a perforated duodenal ulcer, does not benefi t

from drainage. It is well established that the peritoneal cavity as a whole cannot be drained.

If complete hemostasis cannot be achieved in the vicinity of an anastomosis, there may be some merit to inserting a silicone closed suction drain for a few days to prevent pool-ing of blood next to the anastomosis, provided the drain does not come into direct contact with the suture line. In truth, there is no substitute for excellent hemostasis.

Further Reading

Deitch E. Placement and use of drains. In: Tools of the trade and rules of the road. A practical guide. Philadelphia: Lippincott-Raven; 1997. p. 91–102.

Dellinger EP, Steer M, Weinstein M, Kirshenbaum G. Adverse reac-tions following T-tube removal. World J Surg. 1982;6:610.

Diener MK, Tadjalli-Mehr K, Wente MN, Kieser M, Buchler MW, Seiler CM. Risk-benefi t assessment of closed intra-abdominal drains after pancreatic surgery: a systematic review and meta- analysis assessing the current state of the evidence. Langenbecks Arch Surg. 2011;396:41–52.

Gillmore D, McSwain NE, Browder IW. Hepatic trauma: to drain or not to drain? J Trauma. 1987;27:898.

Hoffman J, Shokouh-Amiri MH, Damm P, et al. A prospective, con-trolled study of prophylactic drainage after colonic anastomoses. Dis Colon Rectum. 1987;24:259.

Kim YI, Hwang YJ, Chun JM, Chun BY. Practical experience of a no abdominal drainage policy in patients undergoing liver resection. Hepatogastroenterology. 2007;54:1542–5.

Memon MA, Memon B, Memon MI, Donohue JH. The uses and abuses of drains in abdominal surgery. Hosp Med. 2002;63:282–8.

Robinson JO. Surgical drainage: an historical perspective. Br J Surg. 1986;73:422.

C.E.H. Scott-Conner and J.L. Chassin